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MMIS User’s Guide for DSS C-1
Chapter C-Enrollment 5/12/2014
Table of Contents
ACCESSING THE ENROLLMENT MENU C-3
INQUIRY FUNCTION C-7
INQUIRY BY CASE NUMBER C-7
INQUIRY BY MEMBER ID NUMBER C-8 INQUIRY BY MEMBER NAME C-9
ADD FUNCTION C-10
ADDING A NEW CASE AND A NEW MEMBER C-10 ADDING A NEW CASE FOR AN EXISTING MEMBER C-14
ADD A NEW MEMBER TO AN EXISTING CASE C-15 ENTERING MEMBERS WITH OUT OF STATE MAILING ADDRESSES C-18
ATTACH AN EXISTING ENROLLEE TO AN EXISTING CASE C-22
UPDATE FUNCTION C-25 CHANGING CASE DATA C-25 CHANGING MEMBER DATA C-26
CHANGING MEMBER AID CATEGORY CODE C-27
CANCEL FUNCTION C-28 CANCELLING ELIGIBILITY C-28
REINSTATING MEMBER COVERAGE C-30
RETRO CANCEL REINSTATE FUNCTION C-31 USING RETRO CANCEL REINSTATE REASON CODE 024 C-31 USING RETRO CANCEL REINSTATE REASON CODE 032 C-34
CASE NUMBERING C-36
MEMBER NUMBERING C-36
DUPLICATE MEMBER PROCESS C-37 DUPLICATE REVIEW REQUESTS C-37
REPORTING FPL STATUS C-38
REQUEST AN ID CARD C-40
VIEWING PREVIOUS MEMBER INFORMATION C-41
POWER OF ATTORNEY/AUTHORIZED REPRESENTATIVE STATEMENTS C-43
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ENROLLING A MEMBER IN EMERGENCY SERVICES MEDICAID C-45
ENROLLING A MEMBER IN DIALYSIS MEDICAID C-48
ENROLL A QUALIFIED INDIVIDUAL (QI) C-50
PLAN FIRST COVERAGE C-52
REFUGEE MEDICAL ASSISTANCE C-52
EXTENDED MEDICAID C-53 OVERVIEW C-53 EXTENDED MEDICAID WORKFLOW C-53 CANCELLATION CODES AND ERROR CORRECTION C-56 ERROR CORRECTION C-56
VIEW OF THE PROCESS C-57
LIMITED COVERAGE GROUPS REQUIREMENTS C-57 QUALIFIED MEDICARE BENEFICIARIES (QMB) C-57 SPECIAL LOW-INCOME MEDICARE BENEFICIARIES (SLMB) C-57
QUALIFIED INDIVIDUALS (QI) C-58 QUALIFIED DISABLED WORKING INDIVIDUALS C-58
PLAN FIRST C-58
MMIS User’s Guide for DSS C-3
Chapter C-Enrollment 5/12/2014
Accessing the Enrollment Menu
From the MMIS Main Systems Menu choose the Member Sub-System tab.
From the Member Subsystem Menu click in the Enrollment radio button.
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The Enrollment Menu screen allows for Inquiry, Add, and Update functions for case
and member data.
Enrollment Menu Field Definitions
Select Enrollment Type: Allows selection of type of record to be accessed.
Select Function: Allows selection of a function. Cancel, Retro Cancel
Reinstate, and ID Card Request are only valid with
enrollment type of member. The Add function may only be
used with enrollment type Case and Enrollee.
Reissue Reason: The reason code explaining why a plastic card is being
reissued to a member. Required when ID Card Request
function is chosen. See table below for values.
C Change of Demographic Information (only system entered)
D Destroyed
I Initial Card
L Lost
S Stolen
Case ID: Member case ID number; the member case ID number
uniquely identifies the family or group of individuals in the
same case entity.
Member ID: Member’s unique 12 digit ID number.
SSN: Member’s Social Security number.
VACIS/ADAPT ID: Member client ID number in the ADAPT system if
applicable. ADAPT is a LDSS system used for LDSS
administered programs.
VaCMS Member ID: Member client ID number in the VaCMS system if
applicable. VaCMS is a LDSS system used for LDSS
administered programs.
Last Name: Member’s last name.
Suffix: Member’s suffix if any.
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First Name: Member’s first name.
Middle Initial: Member’s middle initial if any.
DOB: Member’s date of birth.
Gender: A code indicating the gender of the member. “M” = Male,
“F” = Female, and “U” = Unknown.
Telephone Number: Member telephone number.
HIPP: A unique number assigned to each HIPP/HIV case.
New TDO Enrollee?: “Yes” or “No” radio buttons allowing entry for TDO
(Temporary Detaining Order) entry.
Enter: Command to edit data entered.
Clear Form: Clears all user data from the screen and returns blank
fields.
Member: Branches to the Member Demographics screen. Member
number must be present. Can only be used with Update
and Inquiry functions.
Eligibility: Branches to the Eligibility Data Screen. Member number
must be present. Can only be used with Update, Inquiry,
Retro Cancel Reinstate, and Cancel functions.
TDO: Branch to the Temporary Detaining Order screen. Member
number must be present. Can only be used with Update
and Inquiry functions.
Financial: Branch to Member Financials screen. Member number
must be present. Can only be used with Update and Inquiry
functions.
Case: Branch to the Case Data maintenance screen. Case number
must be present. Can only be used with Update and Inquiry
functions.
TPL Sum: Branch to the TPL Summary screen. Member number must
be present. Can only be used with Update and Inquiry
functions.
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ID X-Ref: Branch to the ID X-Ref screen. Member ID must be
present. Not applicable when a function is chosen.
Override: Branches to VA Medicaid Duplicate Member screen.
Access restricted to DMAS use only.
Sub Menu: Return to the Member Subsystem Menu.
Main Menu: Return to the Main System Menu.
Dup Mem: Branches to the VA Medicaid Duplicate Member screen.
Can only be used with Inquiry function. Access is
restricted to authorized DMAS and DSS users.
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Inquiry Function
Inquiry by Case Number
From the Enrollment Menu select Case and Inquiry. Next, enter the case number in
the Case ID field and then press Enter.
The Case Data Screen will display the case data and all attached members. From this
screen inquire on any of the members displayed by choosing the radio button to the
left of the member ID and then selecting the screen to view.
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Inquiry by Member ID Number
From the Enrollment Menu select Member and Inquiry. Next, enter the Member ID
number in Member ID field and press Enter. The Member Demographics Screen will
display the demographic data for the member.
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Inquiry by Member Name
An inquiry by name can be performed from the Enrollment Menu by the member’s last
name, first and last names, or by entering a partial name (at least the first three letters of
the first and last name followed by %).
Input member name
Select Enter after member data is input
All matches for the criteria entered is displayed. Select the radio button beside the
correct member.
Select the button for the screen to be viewed for that member.
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Add Function
Adding a New Case and a New Member
From the Enrollment Menu select Case and Member and Add
Next, key in the following fields and select Enter
First 11 digits of the Case ID*
First 11 digits of the Member ID*
SSN*
VACIS/ADAPT ID
Last Name*
Suffix
First Name*
Middle Initial
DOB*
Gender*
Telephone Number
HIPP
*These are mandatory fields and data must be input when using this function.
The Case Data Screen will display. Key in the member’s data in the following fields:
ADAPT ID
Last Name*
First Name*
Middle Initial
Suffix
Address**
City*
State*
Zip Code*
Case SSN*
Caseworker*
Case FIPS*
Review Date*
Follow-Up Code
Follow-Up Date
*These are mandatory fields and are required to add case data.
**If the member’s mailing address is out of state the member’s mailing address
should be entered here.
Next, select Enter, verify the data is correct, and then select Member.
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On the Member Demographics screen input the member data. Mandatory fields on
this screen are:
Relationship to Case Head
Race
Marital Status
Primary Language
Cit Status
Cit Level
Identity
Country
Same as Case Address*
Same as Case FIPS*
*If the member address is the same as the Case Address and/or the Case FIPS a “Y” for
“Yes” should be entered. If either address is different a “N” for “No” should be entered
and the appropriate additional data (Mem FIPS and/or Member Address) should be
entered on this screen. If the member’s mailing address is out of state, the member’s
mailing address should be entered on this screen.
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After all data has been input select Enter to validate information and then select
Eligibility.
In the Eligibility Data screen enter the member’s aid category, application date, and
begin date. If a closed period of coverage is being entered an end date should be
input.
Select Enter to view the Member Benefits screen and validate eligibility information.
Select Update to save data. “Data Added” will appear at bottom of screen after
successful update.
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Adding a New Case for an Existing Member
From the Enrollment Menu select Case and Add. Enter the first 11 digits of the case
number and the entire existing member’s ID number.
Select Enter.
In the Case Data screen input the case information. Note the Attach Member ID to
Case field is already populated with the member ID that was input. The relationship
of the member ID to the case head must be entered.
Select Enter to validate
Select Update to save. “Data Added” will appear at bottom of screen after successful
update.
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Add a New Member to an Existing Case
From the Enrollment Menu select Member and Add.
Enter the case number, the first 11 digits of the member ID number, and required
member information.
Select Enter.
On the Member Demographics screen input the member data. Mandatory fields on
this screen are:
Relationship to Case Head
Race
Marital Status
Primary Language
Cit Status
Cit Level
Identity
Country
Same as Case Address*
Same as Case FIPS*
*If the member address is the same as the Case Address and/or the Case FIPS a “Y” for
“Yes” should be entered. If either address is different a “N” for “No” should be entered
and the appropriate additional data (Mem FIPS and/or Member Address) should be
entered on this screen. If the member’s mailing address is out of state the member’s
mailing address should be entered on this screen.
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After all data has been input select Enter to validate information and then select
Eligibility.
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In the Eligibility Data screen enter the member’s aid category, application date, and begin
date. If a closed period of coverage is being entered, the end date should be input.
Select Enter to view the Member Benefits screen and validate eligibility information
Select Update to save data. “Data Added” will appear at bottom of screen after
successful update.
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Entering Members with Out of State Mailing Addresses
Managed care pre-assignment and assignment letters are mailed to the address located on
the Case Data screen. This is unlike other mail that is driven to the address located on the
Member Demographic screen. As a result, members who have out of state mailing
addresses must have address data input into the MMIS in a specific way to prevent
DMAS cancellation of the member’s eligibility. Members who reside in the state of
Virginia, but have mailing addresses that are in another state should have addresses
entered into the MMIS as follows:
Member mailing address (out of state) is entered on the Case Data screen
On the Member Demographic screen enter “Y” for Yes in the “Same as Case
Address” field. This will populate the out of state mailing address on the Member
Demographic screen.
The member’s physical address (where the member resides in the state of Virginia)
should be entered in the Comments section of the Member Comments screen. This is
done by selecting the Comments button on the Case Data screen while in Update
mode. The member’s physical address showing that the residence is in the state of
Virginia must be noted on the Member Comments screen or DMAS will close the
member’s eligibility with temporary cancel reason 012 as it will appear the member
does not live in the state.
The following three screen shots show an example of a member whose mailing
address is in West Virginia, however, the member’s physical address is in the state
of Virginia.
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Attach an Existing Enrollee to an Existing Case
From the Enrollment Menu select Case and Update
Enter the Case ID
Select Enter.
In the Case Data screen enter the member ID number in the Attach Member ID to
Case field
Input the member’s relationship code in the Relationship field
Select Enter to validate information
Select Update to save
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The Case Data screen will populate showing all members that are now attached to the
case.
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Update Function
Changing Case Data
From the Enrollment Menu select Case and Update
Enter the Case ID number
Select Enter
In the Case Data screen input any case changes such as the case name, address*,
worker number, or review date
Select Enter to validate
Select Update to save
*See page C-18 for entering members with out of state mailing addresses.
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Changing Member Data
From the Enrollment Menu select Member and Update
Input the member ID number
Select Enter
In the Member Demographics screen input new member information*
Select Enter to validate changes
Select Update to save.
NOTE: Never overlay a member’s information with another member’s information
in this screen. If a change is being made on permanent member information such as
DOB or SSN an explanation should be placed in the Comment screen for reference.
*See page C-18 for entering members with out of state mailing addresses.
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Changing Member Aid Category Code
Aid Categories are used to determine:
What services are covered by Medicaid for the member,
To determine managed care organization (MCO) assignment and capitation
payment amounts, and
To categorize types of enrollments for reporting
Aid categories are not changed retroactively unless there is an increase in the member’s
benefit level or when moving between long-term care and auxiliary grant aid categories.
Decreases or termination of a member’s benefit level are never changed retroactively –
only prospectively. Changes in aid categories that do not affect the member’s benefit
level are only made prospectively.
If the aid category is changing but the benefit level is staying the same or if the aid
category is changing and the benefit level is decreasing the existing coverage should be
cancelled at the end of the month or the following month if change is being made after
cut-off. The new aid category should then be entered beginning the first of the month
following the closure.
Changes in aid categories that increase a member’s benefit level are made by using the
Retro Cancel Reinstate function or, for closed spenddown eligibility segments, sending a
Coverage Correction Request Form to the DMAS Eligibility and Enrollment Unit. (See
Chapter A for contact information or the SPARK Page for forms.)
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Cancel Function
Cancelling Eligibility
From the Enrollment Menu select Member and Cancel
Input the member ID number
Select Enter
In the Eligibility Data screen input the Cancel Reason code (see Help for valid
values) and the cancel date
Select Enter to validate
Select Update to save; “Data Added” will appear at bottom of screen after successful
update.
Two cancel reason codes of importance:
Cancel Reason 070: Allows the LDSS to void coverage that was added in error on
the same day.
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Cancel Reason 071: Allows the LDSS to void future coverage that has a begin date
more than four days in the future.
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Reinstating Member Coverage
From the Enrollment Menu select Member and Update
Input the member ID number
Select Eligibility
At the Eligibility Data screen input the member’s new aid category, application
date, and reinstate reason (enter end date if closed period of coverage)
Select Enter to validate
Update to save, “Data Added” will appear at bottom of screen after successful
update
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Retro Cancel Reinstate Function
The Retro Cancel Reinstate function allows for the retroactive entry of a new aid
category with greater ongoing benefit coverage (Reason 024) or for the entry of a change
from auxiliary grant to long-term care (or vice versa) aid categories (Reason 032). The
retroactive cancellation date cannot be more than one year in the past. Changes greater
than one year in the past require entry by DMAS staff. Send a Coverage Correction form
to the DMAS Eligibility and Enrollment Unit at Enrollment@dmas.virginia.gov.
The Retro Cancel Reinstate function should never be used for entry of closed periods of
coverage as this function does not allow for entry of an end date. For closed spenddown
eligibility segments, send a Coverage Correction Request Form to the DMAS Eligibility
and Enrollment Unit. (See Chapter A for contact information or the SPARK Page for
forms.)
Using Retro Cancel Reinstate Reason Code 024
From the Enrollment Menu select Member and Retro Cancel Reinstate
Input the Member ID number
Select Enter
Select the line of eligibility that is being replaced by clicking in the radio button to the
left of the eligibility segment
Enter cancel reason code 024
On the top line enter the new covered group information
Select Enter to validate data
Select Update to save
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The Member Benefits screen will now reflect the new greater eligibility segment start
date and the end date of the segment that was replaced.
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Using Retro Cancel Reinstate Reason Code 032
From the Enrollment Menu select Member and Retro Cancel Reinstate
Input the Member ID number
Select Enter
Select the line of eligibility that is being replaced by clicking in the radio button to the
left of the eligibility segment
Enter cancel reason code 032
On the top line enter the new AG or LTC benefit information
Select Enter to validate data
Select Update to save
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The Member Benefits screen will now reflect the new aid category.
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Case Numbering
For new applications or when a member becomes eligible for Supplemental Security
Income (SSI), the member is placed in the same case with other family members.
Member Numbering
Once a member is assigned a member ID number, that number remains with that member
even when it is necessary to change the case number under which the member was
initially enrolled. The number that is assigned to the member is used for all subsequent
enrollments regardless of the leading digits, program, or aid category the member was
previously assigned to. This includes State and Local Hospitalization (SLS), Temporary
Detention Orders (TDO), and special screening aid categories (those that begin with a
prefix of “975”).
The only exception to this rule is in the event a foster care child is adopted AND
assigned a new SSN. When an adopted child receives a new SSN the existing
enrollment should be closed and a new member ID number should be assigned for the
child in the adoptive parent’s case. If the child does not receive a new SSN and the
adoptive parent has a Medicaid case, the same member ID should continue to be used,
attach the existing number to the new adoptive parent’s case number.
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Duplicate Member Process
Prior to enrolling a member into the MMIS, system searches should be performed to
ensure the duplicate is not already enrolled. Searches should be performed by Social
Security Number and by member name.
Assigning duplicate member ID numbers results in issues with the member’s enrollment
and benefits. Service limits are linked to the member’s ID number, therefore, assigning a
new number to a member starts a new service history. Duplicate ID numbers can cause
complications with managed care services as well as client medical management.
Duplicate member numbers may result in duplicate capitation payments to the provider.
In the event the LDSS discovers that a member has been assigned two member ID
numbers, the LDSS should determine which member ID is the member’s permanent ID
and which number should be the associate ID. A MMIS Duplicate Member ID Link
Request Form should be completed and submitted to the Eligibility and Enrollment Unit
at DMAS to Enrollment@dmas.virginia.gov. The member ID numbers will be linked
together in order to have a complete record of the member’s eligibility.
Duplicate Review Requests
If a “Possible Duplicate” is identified and the LDSS does not believe the duplicate is the
same person that is being added or changed, a Duplicate Member Review should be
requested by taking the following steps:
When Duplicate is Identified in ADAPT
Log in to the MMIS
Enter the Member ID number
Select Dup Mem
In the Duplicate Member Review screen enter “Y” in the Req Review field
Select Enter
Select Update to save the request
When Duplicate is Identified in MMIS
Select Dup Mem from the Enrollment Menu or the Demographics screen to view the
possible duplicates
If the possible duplicate is not the same member that is being added or changed
request a review by entering “Y” in the Req Review field
Select Enter
Select Update to save the request
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DMAS will then review the request to determine if a duplicate member exists. DMAS
will take one of the following actions on the request:
“A” – Approve the review; indicating the two members are not duplicates
“D” – Deny the review; member is a duplicate to an existing member.
Link the member ID number if it is in an update/change transaction and the possible
duplicate is the same person.
Note: DMAS will never approve a duplicate on the same SSN. In the event the two
members have the same SSN the LDSS will need to run a SOLQ search to determine
which SSN is correct. If the “possible duplicate” member’s SSN is incorrect and the
eligibility status is still ongoing, contact the LDSS for that member to correct the SSN.
For additional information regarding duplicate members in the MMIS please refer to
Broadcast 6645.
Reporting FPL Status
The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003
established a prescription drug benefit, Part D. As a result of this legislation, Medicaid
no longer provides prescription drug coverage for full-benefit Medicaid members who
are also enrolled in Medicare Part A and/or Part B (dually eligible members). Dually
eligible Medicaid Members are required to receive their prescription drug coverage under
Medicare Part D. Medicaid members do not pay a premium for Part D coverage;
however, a co-payment is required for members except those in nursing facilities and
ICF-MRs. The co-payment amount is based upon whether the member’s income is equal
to or less than 100% of the Federal Poverty Limit (FPL) or above 100% of the FPL.
The FPL status indicator, which is found on the Member Benefits screen has two values
for the data field:
“Y” = “Yes” Income is Less Than or = 100% FPL
“N” = “No” Income is Not Less Than or = 100% FPL
Non-Medicaid aid categories such as FAMIS are not reported and therefore no FPL status
is displayed. The FPL status will be automatically entered by the MMIS for those aid
categories where the income is known to be above or below 100% of the FPL with a “Y”
or a “N”. For those aid categories where the FPL status is unknown the indicator will be
a “U” for unknown and the worker will need to change the status to either “Y” or “N” to
complete the enrollment in the new aid category.
The Eligibility Data screen reflects the FPL status that is associated with the aid category
that is currently active. The date to the right of the FPL status reflects the month and year
that this FPL status became effective.
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The Member Benefit screen reflects the FPL status associated with the selected eligibility
segment. The date to the right of the FPL status shows the date the status became (or will
become) effective.
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Request an ID Card
At the Enrollment Menu select Member and ID Card Request
Key in the reissue reason
C Change of Demographic Information (only system entered)
D Destroyed
I Initial Card
L Lost
S Stolen
Input the Member ID number
Select Enter
At the Member Demographics screen confirm member information and choose
ID/CID to complete request.
Note: Verify that the Suppress ID Card field is not set to “Y” for yes on the Member
Demographic screen. If this field is set to “Y” a card will not be mailed to the member.
If a message is received stating that a card cannot be issued until the count is reset an
email should be sent to the Eligibility and Enrollment Unit of DMAS requesting a reset at
Enrollment@dmas.virginia.gov.
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Viewing Previous Member Information
From the Member Demographics screen previous FIPS codes, names, addresses, and
aliases can be viewed.
Enter the Member Demographics screen in Inquiry mode
Click the radio button of the history to be viewed
Select Enter.
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Member history as well as the beginning and end dates of that history are shown.
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Power of Attorney/Authorized Representative Statements
Due to HIPPA privacy regulations LDSS and DMAS staff are only able to speak to
Members, case heads, or authorized representatives regarding a member’s Medicaid
coverage. All authorized representative or power of attorney information that is on file at
the LDSS must be documented in the comment section of the Member Demographics
screen.
Enter the Member Demographics screen in Update mode
Select Comments
Input the Authorized Representative information
Select Enter to validate data
Select Update to save.
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The Comments indicator in the Member Demographics screen is now changed to “Y” for
Yes alerting workers that comments are present regarding this member. The Comments
indicator can be seen in the Member Demographic, Case Data screen, Eligibility Data
and Member Benefits screens.
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Enrolling a Member in Emergency Services Medicaid
Input the member demographics as usual
Indicate that the member is an alien by entering an “A” (Undocumented/Illegal Alien
or Legal Alien Eligible for Emergency Services Only) for the citizenship code
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Input the member’s eligibility in the Eligibility screen. The beginning and end dates
of approved Emergency Services must be entered. The Member Benefits screen will
reflect the beginning and end dates of the Emergency Services Medicaid (XIX FFS
EME). If this line is not present DO NOT select Update to save the enrollment.
This indicates that an “A” was not entered for the citizenship code. This must be
done prior to entering the eligibility for the member or the member benefits will
reflect full Medicaid coverage.
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Note the cancel reason in the Eligibility Data screen is “020” (Automatic Cancellation for
Alien Eligibility – Emergency Services). This cancel reason is a systems generated code
that is input for members with a citizenship code of “A” and indicates that the member is
only eligible for approved Emergency Services Medicaid on specific dates.
In the event a member is incorrectly enrolled for Emergency Services Medicaid a
Coverage Correction form will need to be sent to the Eligibility and Enrollment Unit at
DMAS at Enrollment@dmas.virginia.gov. Note: ID cards are not generated for
members enrolled in Emergency Services Medicaid. The paper approval form is used by
the member and provider for billing and claims purposes.
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Enrolling a Member in Dialysis Medicaid
Input the member demographics as usual
Indicate that the member is an alien by entering a “D” (Undocumented/Illegal Alien
or Legal Alien Eligible for Dialysis Services Only) for the citizenship code.
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Input the member’s eligibility in the Eligibility Data screen; include the beginning
and end dates of approved dialysis coverage.
The Member Benefits screen will reflect the beginning and end dates of the Emergency
Dialysis Medicaid (XIX FFS DIA). If this line is not present DO NOT select Update to
save the enrollment. This indicates that a “D” was not entered for the citizenship code.
This must be done prior to entering the eligibility for the member or the member benefits
will reflect full Medicaid coverage.
In the event a member is incorrectly enrolled for Emergency Dialysis Medicaid and
Coverage Correction form will need to be sent to the Eligibility and Enrollment Unit at
DMAS at Enrollment@dmas.virginia.gov. Note: ID cards are not generated for
members enrolled in Emergency Dialysis Medicaid. The paper approval form is used by
the member and provider for billing and claims purposes.
MMIS User’s Guide for DSS C-50
Chapter C-Enrollment 5/12/2014
Enroll a Qualified Individual (QI)
An individual enrolled as a QI will have their Medicare Part B premium paid for by the
Medicaid program as long as funds are available. Coverage as a QI is not an entitlement;
states receive a capped allocation each calendar year. Enrollment is only for the calendar
year in which an application is filed. The application date, begin date, and end date all
must be within the same calendar year.
Begin Date
The Begin Date of coverage must be in the calendar year for which the application was
filed and cannot be any earlier than January 1. Retroactive eligibility is allowed as long as
it is within the calendar year that the application was filed.
On the initial enrollment of a member in AC 056 the Medicare premium benefit plan
automatically default to a “P” (pending) status. At cutoff, around the 16th
of each month,
the MMIS checks to see if funds are available. If funds are available, the status will
change from a “P” to an “A”. If funds are not available, a system generated letter is sent
to the member. Funds are only available for payment of the Medicare Part B premium
for AC 056 for the current calendar year and the previous calendar year. The MMIS
cannot process payment of premiums for a year prior to the previous year. Example:
today’s date is 2/1/12; the payment of premiums cannot be processed for an individual
enrolled in AC 056 for calendar year 2010.
End Date
If coverage is added without an end date the MMIS will default the end date to December
31st. At cutoff in December of each calendar year the MMIS will cancel coverage
effective December 31st, for all AC 056 members for that calendar year with cancel
reason 027 (QI – Automatic cancellation end of calendar year). A system generated letter
is sent notifying the member of the closure action and advising the member that they
must reapply the next calendar year for coverage in this group. (Note: The wording in
the system generated letter has remained unchanged, although per Medicaid Manual
M1520.200.F.9, ABD renewal form #032-03-0186 may now be used to renew QI
coverage provided there is no break in Medicaid eligibility.) Workers will continue to be
required to reinstate QI coverage until MMIS system changes can be made.
Coverage Added after December Cutoff
If coverage for the current year is added after cut-off in December, that coverage will not
close or be evaluated for funds until cut-off in the month that the eligibility was entered
in the MMIS. This will keep you from being able to enter a January enrollment for the
following year until after January 16th
. If a December application is being processed in
January, and a January application has also been received, cancel the enrollment entered
for the previous year with a cancel reason 024. This will allow the entry of the next years
application with a January begin date. At January cut-off both the new and older segment
MMIS User’s Guide for DSS C-51
Chapter C-Enrollment 5/12/2014
will be evaluated for funds and processed accordingly. If funds are available the segments
will be included in the monthly Buy-In processing.
MMIS User’s Guide for DSS C-52
Chapter C-Enrollment 5/12/2014
Plan First Coverage
Applicants may be eligible for Plan First if they have income less than or equal to 200%
of the FPL, meet nonfinancial requirements, and are not eligible in any other Medicaid or
FAMIS covered group. Members who are losing Medicaid benefits, or apply for but do
not meet another eligibility category, should be evaluated for Plan First coverage.
Applicants may request up to three months of retroactive Plan First coverage. Enroll
applicants approved for Plan First in the MMIS under AC 080. Plan First members are
eligible for family planning services only, including transportation to a family planning
visit or pharmacy to pick up their prescription for contraception.
Refugee Medical Assistance
Refugee Medical Assistance (RMA) is a short-term, federally funded program designed
to ensure refugees receive needed medical care while they transition to life in the United
States. As a result of hardships in their homeland many refugees have had limited, if any,
access to medical care so RMA provides access to care in order to reduce the risk of
health issues that will delay self-sufficiency.
RMA is a program of last resort to be utilized after an individual has been determined
ineligible for Medicaid or FAMIS. Refugee enrollments consist of two aid categories:
078 - Refugee Other or Refugee Medicaid Other
079 - Refugee Medicaid Unaccompanied Minor
The following information must be entered in the Member Demographics screen to enter
Refugee Medicaid eligibility:
The citizenship code must be an “R” (Refugee).
Input the country and the U.S. date of entry.
Aid category 078 allows coverage for up to eight months after the U.S. entry date. The
month of entry begins the first month. The MMIS will automatically close the member’s
enrollment in AC 078 with cancel reason code 021 (Refugee in AC 078 Reached Eight
Month Eligibility Limitation). Members can continue in aid category 079 until the
member reaches age 19. The MMIS will automatically cancel coverage the month the
member turn age 19 with cancel reason code 009 (Foster Care/Adoption Child Age 21 or
Refugee “UM”; LIFC Related Child Age 19).
MMIS User’s Guide for DSS C-53
Chapter C-Enrollment 5/12/2014
Extended Medicaid
Overview
The 12 month extended Medicaid process relies upon the use of the follow-up code. The
follow-up code allows for:
Identifying cases where the extension is due to expire
Automatically generating earning notices
Automatically cancelling coverage if the extension code is not updated correctly and
timely.
Extended Medicaid Workflow
A follow-up code is entered by the LDSS
The MMIS automatically generates notification letters and earning reports for the
recipient to complete and return to the LDSS.
When eligibility reports are returned timely and all requirements are met, the LDSS is
responsible for updating the follow-up code in the MMIS in order for the extension to
continue.
In the event the earnings report is not received time the MMIS automatically cancels
the member’s coverage and generates and Advances Notice of Cancellation. It is not
necessary for the LDSS to take any action.
In the 12th
month of the extension, the MMIS automatically cancels the member’s
coverage if it is still open.
Month LDSS Action MMIS Action
1 Enter follow-up code X1 and date None
2 None None
3 None 1. Send first report on the second of
the month.
2. Follow up code will reflect XA
indicating report has been sent.
4 If report is received from the member
by the 21st the LDSS will confirm
ongoing eligibility with the following
information:
1. Is the child(ren) still in the home?
2. Is the earnings report complete?
3. Are paychecks attached?
4. Has day care been verified?
None
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Chapter C-Enrollment 5/12/2014
If yes to questions one through three,
the LDSS will update the follow-up
code to X2 by the end of the 5th
month.
If no to any of the above or not if
report was not received, request
current income verification.
5 If no to any of questions one through
three in month four or the report was
not received and income was verified
determine if the member is eligible in
another covered group.
If report was not received and income
was not verified, take no action.
System closure will occur in month
six.
None
6 Change enrollment for any members
eligible by cut-off to prevent
erroneous closures.
Sends second report on the second of
the month (Coded X2 to indicate the
first report was received). The follow-
up code is updated to XB to indicate
the report was sent.
OR
If code XA has not been updated prior
to the end of the fifth month, coverage
is cancelled with a reason code 025 at
cut-off and Notice of Closure is sent.
7 If the report is received by the 21st of
the month the LDSS will determine
ongoing eligibility with the following
information:
1. Is the child(ren) still in the home?
2. Is the income verified for all three
months?
If yes to both of the above questions,
the LDSS should use the following
formula:
The months gross income – 3 months
verified daycare/3 = monthly amount.
The monthly amount should then be
compared to the income limits. If the
member remains eligible, update the
follow-up code to X3 prior to cut-off
in the 8th
month. If the member is
None
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Chapter C-Enrollment 5/12/2014
ineligible or the report was not
received, request income verification.
8 If ineligible or not received and the
income was verified, determine
eligibility in another covered group.
Prior to cut-off update enrollment for
anyone eligible or close any members
who are no longer eligible.
If follow-up code remains XB coverage
will be closed with a cancel reason of
025 and a Notice of Closure will be
sent.
9 None The third report is sent on the second of
the month. Follow-up code is updated
to XC to indicate the report was sent.
10 If report is received by the 21st of the
month the LDSS will determine
ongoing eligibility with the following
information:
1. Is the child(ren) still in the home?
2. Is the income verified for all three
months?
If yes to both of the above questions,
the LDSS should use the following
formula:
The months gross income – 3 months
verified daycare/3 = monthly amount.
The monthly amount should then be
compared to the income limits. If the
member remains eligible, update the
follow-up code to X3 prior to cut-off
in the 8th
month. If the member is
ineligible or the report was not
received, request income verification.
None
11 If ineligible or not received and the
income is verified, determine
eligibility in another covered group.
Prior to cut-off change enrollment for
anyone eligible or close to anyone
ineligible.
None
12 Conduct full redetermination of case.
Prior to cut-off update the aid
category as needed and delete the X4
follow-up code for any eligible
members.
At cut-off, close coverage with a cancel
reason 026 and send Notice of Closure
if the follow-up code is X4.
MMIS User’s Guide for DSS C-56
Chapter C-Enrollment 5/12/2014
Cancellation Codes and Error Correction
Cancel Reason 025:
If the Eligibility Worker does not change the Follow-up code by cutoff,
the MMIS, at cutoff in the 6th, 8th, or 11th month will automatically
cancel coverage of each recipient with AC 081, or 083 effective the last
day of the month
Generates an Advance Notice of Medicaid Cancellation
MMIS reports all recipients canceled for this reason on the Families and
Children 12-Month Extended Cancellation List, RS-O-160.
Cancel Reason 026:
When the code is X4, the MMIS will automatically cancel coverage of
recipients with AC 081, or 083 at cutoff in the 12th extension month for
Cancel Reason 026
Generates an Advance Notice of Medicaid Cancellation
MMIS reports all recipients canceled for this reason on the Families and
Children 12-Month Extended Cancellation List, RS-O-160.
Error Correction
If the agency received the earnings report on time but failed to update the code before
cut-off in the 6th, 8th, or 11th month, the MMIS cancels coverage for Reason 025. The
LDSS must:
Manually notify the member of the agency’s error and subsequent
reinstatement
Reinstate the member’s coverage
Correct the follow-up code (will depend upon in which month the case
was erroneously canceled)
If erroneously canceled in the:
6th
Month:
If the code is X1, or XA; and the member has not received the second earnings
request manually send the second earnings request as soon as possible
If the second earnings report and verifications are not received timely or if it is
determined the member is not entitled to the third quarter of coverage, change the
code to X2 by cutoff of the 8th
month
If the second report and verifications are received timely and the member remains
entitled to the third quarter of coverage, change the code to X2 and then
immediately after to X3 by cutoff of the 8th
month to prevent the MMIS from
performing an automatic cancellation.
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Chapter C-Enrollment 5/12/2014
8th
Month:
The code of X2 or XB must be changed to X3 before the start of the 9th extension
month (MMIS will send the third notice/earnings report)
If updating the code after the start of the 9th month, manually send the third
notice/report
Update the code to X4 by cutoff of the 11th month if you receive the
report/verifications on time and determine the member remains entitled to the 12th
month of the extension coverage
11th
Month:
If erroneously cancelled at the end of the 11th
month, change the code to X4.
If the extended coverage data was not entered into the MMIS within the first two
months of the extended coverage period, the follow-up code must be set manually
by the LDSS. This is due to edits on the follow-up code. The code X1 can only
be entered within two months of the current month as the MMIS generates the
letter on the second day of the third month. If the allowable time for entering an
X1 has already passed the coverage can be entered with follow-up code X2
provided it is within five months of the current date as the letter will be generated
on the second day of the sixth month.
View of the Process
The MMIS generates letters and earning reports automatically. The MMIS cancels
coverage only for members whose aid category is an 081 or 083. The letter and report
process typically runs on the second business day of the month, however, this may vary
depending on scheduling changes as a result of weekends or holidays.
Limited Coverage Groups Requirements
Qualified Medicare Beneficiaries (QMB)
Aid categories 023, 043, 063
Eligible for payment of Medicare Part A and Part B premiums, deductibles, and co-
payments.
Must have Medicare coverage on file
Special Low-income Medicare Beneficiaries (SLMB)
Aid category 053
Eligible for payment of Medicare Part B premiums
Must have Medicare coverage on file.
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Qualified Individuals (QI)
Aid category 056
Eligible for payment of Medicare Part B premiums
Must have Medicare coverage on file
Entry of eligibility is only allowed for current and previous calendar year
Application date and begin date must be within same calendar year
Qualified Disabled Working Individuals
Aid caregory 055
Eligible for payment of Medicare Part A premiums
Must have Medicare coverage on file
Plan First
Aid category 080
Plan First members are eligible for family planning (pregnancy prevention) services
only, including transportation to a family planning visit or pharmacy to pick up their
prescription for contraception.